NW2 2019 Support Gainful Employment QIA Monthly Status Report (MSR) MAY Survey

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* 1. Please select your facility from the drop down list below; facility name, CMS Certification Number (CCN - 33-XXXX), and city/town have been included.

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* 2. Your name and contact information

Your Name

e-mail

phone

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* 3. Your facility's current patient census:

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* 4. Have you reached out to your local Independent Living Center?

Yes

If no, WHY?

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* 5. Unconditional Teamwork: What people/programs have you partnered with to promote VR/EN? (Hint: partnering with patient groups, stakeholders, agencies, or other groups of provider staff is considered "Unconditional Teamwork")

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* 6. Please rate the Home Dialysis Central Article: Working on Dialysis: What Staff Should Know

Not Helpful

Useful

Essential

What Article?

Not Helpful

Useful

Essential

What Article?

Comments

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* 7. Since January 2019, have all of your patients (aged 18-54) been screened for VR?

Yes

If NO, why?

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* 8. Do you screen for VR interest in your Plan of Care meetings?

Yes

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* 9. In May how many patients expressed interest in VR?

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* 10. How many patients are eligible for Ticket To Work in your facility? (aged 18-54 and currently on SSI/SSD)

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* 11. Would your patients be interested in on-line (only) VR Classes and counseling?

Yes

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* 12. Have you made any progress in your RCA Intervention? (Hint, are you working on your top barrier identified and using PDSA to see if it is working)

Yes

Were we supposed to do that?

Can you do a refresher webinar on what an RCA is? and how we use PDSA?

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* 13. What is the status of your Education Station/Visual Display?

Complete

In Progress

Procrastinating

What is an Education Station?

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* 14. Would your facility be interested in participating in a Network led Patient Recognition of Achievement Certificate Program? (Providing certificates to and celebrating patients who have achieved milestones - VR,work, school, hobby, volunteerism etc.)

Yes

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* 15. Please share a sample of patient comments on your QIA activities/interactions (Both Positive and Negative)

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* 16. Comments or Questions about this QIAs?

Thank you for completing the May QIA MSR for your facility.

We appreciate your time and effort.

Please click on "DONE" to submit your responses to the Network

Quality Improvement Team

IPRO ESRD Network of New York